large irregular ulcer, which had perforated the colon. In every part of the organ the mucous membrane was diseased. In the greater portion the gastric tubes were scarcely discernible. The solitary glands were much enlarged, and filled with cells and nuclei.

These are all the cases of cancer of the stomach in which my notes enable me to speak positively as to the state of the mucous membrane; but my impres sion is, that it will be found in a morbid condition whenever any part of the organ is affected with scirrhus. Lebert is the only author who, as far as I am aware, has directed attention to this diseased state of the mucous membrane. He does not appear to have examined it with the microscope, but observes that he has found it injected, softened, or thickened at a distance from the seat of the malignant disease. He also remarks that the mucous membrane of the cul-de-sac of the organ is often affected when the cancer does not extend beyond the pylorus.

It is of importance to contrast this state of the structures of the stomach in cancer with that which coexists with simple ulceration. It has been already shown that where a chronic ulcer is present, the mucous membrane presents only chronic inflammation, or patches of degeneration in its immediate neighbourhood. But in cancer the muscular layer is often seriously injured, and the glandular structure is usually to a greater or less extent destroyed. It is therefore, I believe, to these anatomical alterations in the muscular and motor apparatus of the organ that we must look in order to explain many of the more important differences between the symptoms and results of cancerous and simple ulcers.

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Some authors have affirmed that cancerous ulcerations of the stomach occasionally heal in the same way that similar sores do in other parts of the body. Although this may be the case, it has never fallen to my lot to meet with an instance of the kind. Cancer of the stomach runs so rapid a course, and is so generally accompanied by degeneration of the glandular structure of the organ, that there is but little hope of obtaining anything beyond an alleviation of the symptoms by medical treatment.

The most frequent termination of such cases is by exhaustion of the strength of the patient; affording in this respect a striking contrast to the constitutional effects of simple gastric ulcer. Dr. Brinton calculated that only one per cent. of those affected with nonmalignant ulcerations sank from this cause; and Dittrich reckoned this mode of termination at three This difference between cancerous and per cent. simple ulcers is not to be explained by the greater severity of the local symptoms in the former; for the loss of strength in gastric cancer usually precedes the vomiting and pain; and in some cases death has ensued from exhaustion where neither vomiting nor hæmorrhage has been noticed. We must, therefore, refer it to the coexisting degenerations and to the spread of the malignant disease to other organs.

Where, as in the case of the softer forms of cancer, the mucous membrane of the stomach may not present much alteration, we shall probably find that the heart has undergone fatty degeneration. I have not proved this supposition to be correct in any instance of encephaloid disease of the stomach, but I have found it in similar affections of other parts of the digestive canal.

In the majority of cases of malignant disease of the stomach other parts are apt to be affected secondarily. This took place according to the observations of Lebert in thirty-two out of fifty-seven cases. The organs most frequently attacked were the liver, peritoneum, lymphatic glands, the pancreas, lungs, pleuræ, and the bones.

Adhesions are very frequently found between a cancerous stomach and the neighbouring organs. As far as we can draw any inference from the small number in which the position of the attachment is exactly specified, a considerable difference appears to exist between cancerous and simple ulceration in regard to the organ to which the stomach becomes united. Jaksch gives twenty-two cases of adhesion in simple ulceration; and of these fifteen were to the pancreas, five to the liver, one involved the mesentery, and one the spleen. Lebert quotes twenty cases of adhesions of cancerous stomachs, of which number only seven were to the pancreas, twelve to the liver, and one to the colon.

The shape of the stomach is often altered by malignant disease. The amount of contraction is much greater than in the case of simple ulceration, and the distortion is consequently more manifest; thus I have seen the organ reduced to the size and the shape of the colon. Dilatation is a very frequent consequence of a cancerous tumour affecting the pylorus. Lebert found that in one-quarter of his cases this change had been produced, and in some the cardiac region was dilated and the opposite end reduced in size.

The profuse vomitings of blood which are such common results of simple ulceration are rare in

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malignant disease. Occasionally death occurs from this cause, but generally the bleeding takes the form of a constant oozing from the surface of the ulcer. This perhaps arises from the condition of the bloodvessels. In cancerous tumours, and especially in scirrhus, it is a common circumstance to find the arteries blocked up with fibrine during the enlargement of the ulcer, by which severe hæmorrhage is prevented. But in this, as in other malignant sores, the smaller vessels are constantly discharging a bloodycoloured fluid, so that the rapid exhaustion of the patient is partly due to the drain upon his strength.

The danger of death from perforation is much less in cancer than in other forms of ulceration. This arises partly from the more intimate adhesions to the neighbouring organs, and partly from the large amount of new tissue generated at the edges and base of malignant growths.

There is probably no other disease of an equally fatal character in which there is such a variety in the character and number of the symptoms as is presented by different cases of cancer of the stomach. In one they may be so strongly marked that it is almost impossible to mistake the nature of the complaint; in another, it is only by the most careful consideration of the whole of them that the existence of such a formidable malady can be inferred. In like manner each separate symptom presents the greatest variety in different cases, so that we are unable to fix upon any one as certainly indicating the disease.

Pain is one of the most general symptoms of malignant disease of the stomach. The suffering, when

the malady has existed for some time, is usually very severe. By some it is described as a constant gnawing; others compare it to a burning sensation, or complain of a shooting pain, as if a knife were being thrust through the part. It is generally most intense at the epigastrium or behind the sternum, but it is occasionally referred to the hypochondriac regions, to the back, or to various parts of the abdomen. As a general rule, the fixed dorsal pain is less frequently remarked than in simple chronic ulceration; which may be explained by the pancreas being less frequently involved in the disease. The pain is often almost constant, and although it is aggravated by food, it is usually much less so than in simple ulceration. In the earlier stages the suffering is less intense; often only an occasional shooting pain is complained of, or it is present as a dull uneasiness or sense of fulness after eating; but as the disease progresses, it gradually augments both in severity and constancy.

It should be borne in mind that pain is not an invariable accompaniment of cancer. I have found it absent even where a tumour of considerable size could be felt. Every now and then we meet with cases which proceed to a fatal termination without the patient having ever uttered a complaint of suffering, and it is not at all infrequent for the pain felt in the early stages to disappear a few days before death. As a general rule, the pain in cancer differs from that of non-malignant ulceration in its gradual increase, in its greater severity in the later stages, in its being less influenced by the process of digestion, and in its often affecting parts of the abdomen at a distance from the seat of the malady.